* 1. Please indicate the number of people in your household in each age category.

  0 people 1 person 2 people 3 people 4 people 5 people 6 people 7 people 8 people 9 people
Ages 0-15
Ages 16-24
Ages 25-34
Ages 35-44
Ages 45-54
Ages 55-64
Ages 64-74
Ages 75-84
Ages 85+

* 2. Please indicate your level of interest in participating in a neighborhood Village.

  Very interested Somewhat interested Not interested
Increased connection with neighbors through social/educational activities
Getting volunteer help from neighbors
Providing volunteer assistance to neighbors
Getting referrals to professional service providers


Do you hope to remain in your home as you get older (retirement age and beyond)?

* 4. Please indicate what kind(s) of social and educational activities would interest you.  (CHECK ALL THAT APPLY.)

* 5. Please indicate your interest in receiving assistance or providing assistance with/for each of the following.

  Interested in receiving now Likely interested in receiving in the future Willing to help provide
Transportation to medical appointments
Transportation to errands, shopping, taking your child to after school activities, other
Someone to shop for you, pick up prescriptions
Meal preparation assistance or delivery
Babysitting or after school care
Telephone check-ins
Friendly visits
Housekeeping or laundry
Yard maintenance (snow/leaf removal, gardening, mowing)
Home maintenance/handyman help
Computer or electronics assistance
Help with bill paying, taxes, or completing forms
Pet and/or plant care
Taking trash out
Personal care or mobility assistance
Referrals for professional services (e.g., home repair, legal, medical, home nursing)
Other (please specify below)

* 6. Would you like to participate in the planning and organization of a Rock Creek Hills/Kensington Village?

* 7. We need assistance to get our organization started. Please check below any of the areas in which you have expertise and would be willing to volunteer your time to help us.

* 8. Do you know anyone with expertise in one or more of the above areas who might be willing to help us? If yes, would you be willing to contact them on our behalf?

* 9. Would you like us to keep you updated as we develop our program?

* 10. Please provide the following information so we can keep you informed of the progress of our Village.